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[case_id#]
[case_owner_desk_name]
INSTRUCTIONS FOR ARTERIAL FLOW DOPPLER TESTING INCLUDING TOE*
Complete and Return WITH Report
DOPPLER PROTOCOL
Systolic Pressures
Brachial
Systolic Pressure
Right
Left
Right Systolic Pressure
Left Systolic Pressure
Posterior Tibial
Dorsalis Pedis
Great Toe*
If the claimant is missing one or both great toes, please indicate which toes were used:
_____________________________________________________________________________
Ankle/Brachial Ratio: (Use the higher ankle reading from each leg divided by the higher brachial
reading.)
Higher Ankle Pressure =
Higher Brachial Pressure
Ankle/Brachial Ratio
Ankle/Brachial
Ratio
Right
Left
Toe/Brachial*
Ratio
Right
Left
Please send Doppler pulse wave tracings.
__________________________________
Technician Signature
______________
Date
*(If the patient is diagnosed with diabetes mellitus or other small vessel disease,
please obtain resting toe systolic blood pressures and/or resting toe/brachial systolic
blood ratio.)
| File Type | application/pdf |
| File Title | Arterial Doppler Evaluation With Toe |
| Author | Rhonda Rush |
| File Modified | 2022-07-01 |
| File Created | 2022-07-01 |